The Impact of the Privacy Provisions in ARRA

I was recently asked to comment about the resources needed to comply with the Privacy Provisions in the Stimulus Bill.

Here is a brief analysis from my Security Team:

ARRA has a provision that requires covered entities keep a list of all data disclosures to third parties and provide a comprehensive audit log to patients upon request. This tracking of third party data exchange is not currently part of HIPAA requirements and will require significant enhancement to our auditing systems, our patient services reporting tools, and our personal health records which give patient access to their own audit trails.

Based on at least one interpretation of ARRA, the covered entity must take responsibility for patient notification when third parties improperly disclose patient information. There does seem to be some variation in interpretation in this area.

ARRA specifies that disclosure of a record containing a name and medical information (John Smith, Hematocrit 37) is considered a breach. Massachusetts requires the name and at least one other identifiable piece of information (John Smith, 5/23/1962, Hematocrit 37). This could have significant implications since even simple audit logs could be considered restricted/confidential information.

ARRA provides some definition about the actual notification methods required. In breaches where the contact information of more then 10 individuals is not known the covered entity must post the breach on their web site. If the breach is of more the 500 records the covered entity must make a public disclosure to “prominent” media outlets. Prior to this the only obligation was to contact the individuals directly.

ARRA also includes some language that requires covered entities limit the amount and type of information shared with providers to be the minimum required for the business need. It also requires that if patients pay for services out of pocket that covered entities provide a way for the individual to request that no information relative to the treatment be transmitted to any provider.

Privacy is foundational and we certainly cannot argue with the need to keep information confidential per patient preferences. However, some of these provisions, such as the "out of pocket" clause will be extremely challenging to implement.

Over the next few months, HITSP is working on standards which will support these ARRA provisions, including web services using XACML, WS*, and TLS.

As HITSP moves to create a service oriented architecture, we will enhance our existing TN900 Technical Note to include services that could be used to document consent, apply privacy policies and consent to data flows, and transmit the minimum necessary data to authorized clinician via a workflow similar to that I described in a previous blog entry about patient privacy preferences.

The privacy provisions in ARRA will serve as a catalyst to improve the policies and technologies protecting confidentiality. This work, although expensive and time consuming, is required for patients to trust EHRs and Healthcare Information Exchanges.

It's the Network

This week I went live with 1080p life size Teleconferencing in my home using Cisco Telepresence. I'll write an entire blog devoted to my experiences with it next weekend when I attend HIMSS virtually on April 5 from Boston.

To prepare for the installation of Telepresence, I wanted my home network to be as robust as possible, so I chatted with Verizon about upgrading my home FIOS connection to 20 megabits up/20 megabits down.

In the past I wrote about some of the challenges I had with my initial FIOS installation. I'm happy to report that Verizon has worked hard to improve their processes and now FIOS upgrades and support are well coordinated.

My experience with the upgrade felt like the "It's the Network" ads. I had a team calling me, the guy with glasses showing up at the door, and followup calls. The end result was a perfect 20/20 connection without interruption of my service.

The Cisco folks connected a Cisco 800 series router to my FIOS connection to ensure Quality of Service for the Telepresence device and to automatically create a VPN tunnel to the Cisco Telepresence Exchange.

As of today, my home telecommunications infrastructure is:

A Verizon Fiber connection from the street through a conduit to a home-based main distribution frame (MDF), in my basement, supported by a backup power supply.

A Cat 6 cable connects the Verizon infrastructure to the Cisco 800 series router which is connected to the Telepresence unit.

The Cisco 800 series is then connected to a Verizon provided router (Action-Tec) which connects to my network printer, an iMac 20, and my Apple Airport Extreme 802.11n wireless router.

My Airport Extreme provides 90 megabits/second wireless connectivity throughout my home and connects to my two Terabyte home storage cloud (a Western Digital MyBook Studio RAID 1 backup device)

Thus, in my basement I now have a communication infrastructure which is as good as many commercial sites - a 20 megabit connection with backup power, video teleconferencing, network printing, a cloud of network storage and 802.11n high speed wireless networking with WPA security.

We tested the jitter and latency of my home network on the Cisco Telepresence worldwide network. It was remarkably low, ensuring extremely high quality Telepresence performance. We connected to Telepresence engineers in North Carolina, California and Texas. The experience of home Telepresence matched that of every high end teleconference I've ever done - life sized 1080p with no pixelation and perfect sound quality.

In an era when we're all reducing our travel budgets and limiting our time away for the office, Telepresence is as good as being there.

For folks I've met before and already established a working relationship with, I cannot think of a reason to fly to a meeting when I have Telepresence.

Now, I'll have to work on my lecture schedule. Hopefully, the culture which demands a physical speaker at the podium will accept a virtual podium when it means I can lecture more frequently from my basement instead 24 hours of travel through Logan Airport.

Cool Technology of the Week

Last Thursday, I flew to Houston to keynote Pri-Med and sat next to Kedaar Kumar, a composer and sound designer for Harmonix.

While flying, we talked about my Shakuhachi playing and Zen ideals. Kedaar is also a vegan, shares many of my philosophies, and uses a unique IT approach to composing, called the Monome, which is my Cool Technology of the Week. The Monome is a hand finished wood block with 64 backlit buttons.

The device has a USB 2.0 interface supporting serial, midi and open sound control. The buttons can be configured as toggles, radio groupings, sliders, or organized into more sophisticated systems to monitor and trigger sample playback positions, stream 1-bit video, interact with dynamic physical models, and play games. Button press and visual indication are decoupled by design: the correlation is established by each application.

There are numerous applications which exercise the Monome as a simultaneous input and output device, including

* 64step is a versatile step sequencer aimed at fluid composition and editing.
* mlr is a sample-cutting platform intended for dynamic and performative live manipulation.
* life is an interactive version of conway’s original simulation.
* phoenix is a probabilistic arpeggiator with a drawable waveform.

All related software is open source. This includes the embedded code, routers (monomeserial, serialio and mapd), and applications.

Kedaar demonstrated 7up, an application written in Java that enables the Monome to communicate with any midi-enabled software synth. The primary goal of 7up is to create a self-contained music composition suite where all instruments/controls/samples/loops/etc are intuitively accessible from the Monome itself, eliminating the need to use software on the computer.

Here's a video of the Monome in use.

It's a remarkable bit of engineering and one of the most creative user interfaces I have ever seen. Definitely cool!

Locavore Support Online

It's time for a Thursday lifestyle blog.

As a vegan and locavore, I buy local vegetables, grow my own, and store/preserve foods for the winter months.

Finding fresh, organic vegetables for me includes buying shares in Community Supported Agriculture, in my case from Red Fire Farm.

I also enjoy farmer's markets and local specialty producers of heirloom beans, tofu, and grains.

All of this required a great deal of research and experimentation.

Now there's an App for that!

On the iPhone Store, Locavore is an iPhone/iPod application that tells you when local fresh produce is available and where to find it.

The app is a great resource who anyone who wants to optimize the produce of each season, find it locally, and prepare it using advice from Epicurious or Wikipedia. You can search by your current GPS location, by state, by fruit/vegetable name, and by farmer's market.

Asparagus and Rhubarb are coming into season soon.

10 local farmer's markets within 10 miles of my home have iPhone accessible web links.

For $2.99 I found Locavore a useful application to keep me aligned with bounty of each season.

Green IT for Desktops

BIDMC has worked diligently to reduce operating costs and avoid staff reductions.

IT is doing its part to reducte operating and capital costs. One of our initiatives has been Green IT to reduce the power and cooling expenses of data center, as described in my blogs Kill a Watt and Some Like It Hot.

Our latest effort, announced this week, is power reduction for desktops.

Here's our challenge.

Many of our clinicians require "instant on" computing in clinics and operating rooms. Many of our staff require remote access to their computers via our SSLVPN Remote Desktop features.

How do we power down unused desktops but still meet the need of our stakeholders?

This week, we are modifying the settings of all our desktops - 8000 of them - to power down disk drives and monitors when they are untouched for 20 minutes. As soon as the workstation is used again, power will resume immediately. Thus, there is no need to power off computers manually. We'll do it automatically.

A screen print of our new settings is above.

When I announced this change, several folks were concerned about losing work or disabling their remote access. The systems aren't being powered down or forced into a hibernating state, the monitor is placed in a low power state and the hard drive stops spinning. We didn't want to disrupt work or prevent users from accessing their workstations from home and so this option was the best choice. It provides an opportunity for power savings but does not interfere with remote workers relying on RDP or SSLVPN.

Our commitment to Green IT will save money, improve our carbon footprint, and still meet the needs of all our users. Over time, I believe we'll move to thin client devices without moving parts that will have an even smaller energy footprint.

On a related topic, I was asked today about the kilowatt cost of Electronic Health Records, since the country will be implementing EHRs for 664,000 clinicians as part of the Stimulus Bill. I'm working with my energy experts to calculate our energy footprint using the extremely virtualized server/storage/data center infrastructure we've implemented for our community doctors. I'll report on that soon.

How About Some Good News?

I just watched the Obama news conference and feel compelled to make an observation.

Is it just me or has the news media and the blogosphere become obsessed with bad news?

Many people have questioned Tim Geithner's longevity as Treasury Secretary because of his performance to date. He was confirmed 60 days ago.

How can a single human turn around a multi-trillion dollar economy in 60 days?

Many people have questioned the Obama administration's commitment to Electronic Health Records. Recent articles have challenged the claims of quality improvement, enhanced safety and lower costs. Several of these articles have cherry picked from the few negative studies about EHRs. As you've seen from my blog, leading experts wrote evidence-based summaries of the literature to offer a balanced view on these issues. Neither the Wall Street Journal nor the Washington Post published our submissions.

Every day the press is filled with philosophical discussions from folks outside the trenches, second guessing the plans for the economy, the wars, and healthcare reform.

No one seems to support the idea of steady progress, phased accomplishment, or a positive trajectory. It's been 60 days.

Folks, let's give these folks a chance to do their work, offering our energy to work together to improve the world we live in, not endless criticism of their first efforts. As writer Ben Hecht wrote "Trying to determine what is going on in the world by reading newspapers is like trying to tell the time by watching the second hand of a clock."

The Standards Charter Organization

I've received several emails about the Standards Charter Organization (SCO) recently announced in a press release.

Some folks have asked if SCO is the successor to HITSP or if it changes the landscape of standards harmonization efforts. I've been very close to the work of the SCO, which has been closely aligned with the HITSP Foundations Committee. The SCO is complementary not competitive with HITSP. Here's the full story.

Several standards organizations, NCPDP, HL7, X12 and ASTM, recognized that their individual efforts have organization specific priorities, scope, and component elements such as code sets.

Working together, the SDOs can coordinate their approach to more rapidly close gaps in standards, use common code sets in all their work products and avoid the development of overlapping standards.

By doing this, their individual work products will be "pre-harmonized" in many ways, making the work of HITSP, CCHIT, and implementation guide writers much easier.

The SCO process is just beginning. My hope is that the SCO will work with HITSP in a three ways

* HITSP will be able to hand off gaps in standards to the SCO for assignment to individual SDOs

* The SCO will identify cross-SDO projects and hand them off to the HITSP Foundations Committee for harmonization. Foundations has already worked on creating common code sets such as gender and marital status

* As we all work together to create a Nationwide Health Information Network, the "pre-harmonized" work products from the SDOs will accelerate interoperability

Thus, I completely support the efforts of the SCO. HITSP, SCO, and the HIT Standards Committee are all important parts of the interoperability ecosystem with different roles and responsibilities.

A Healthcare IT Primer

Now that Healthcare IT is part of the stimulus and newsworthy, I receive many questions from reporters about the fundamentals of healthcare IT. Here's a primer with the Top 10 questions and answers:


1. Can you define EHR, EMR, PHR and PM in simple terms?

Electronic Medical Record - An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Electronic Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff, across more than one health care organization.

Personal Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Practice Management - An application used to manage the physician business operations including scheduling, registration, and billing

2. How large is the unserved market for HIT?

There are 800,000 clinicians in the US. 17% have EHRs today. This leaves 664,000 who need EHRs. Over the next 5 years the early to mid-adopters will work hard to gain the full stimulus incentive amounts available in 2011-2012. Late adopters will gain the reduced stimulus available in 2013-2014. Resistors will begin receiving penalties in 2015.

3. How many companies are currently competing in the small practice/ ambulatory EHR market? Are there any clear leaders in terms of client base or innovation?

There are over 100 companies providing EHRs for small practices. In my experience the ambulatory market leaders are eClinicalWorks, Allscripts, NextGen, GE Centricity, and Meditech/LSS (for small practices tightly affiliated to a hospital using Meditech). Epic is a market leader but not for small practices.

4. What does “meaningful use” really mean? Do you think physicians currently feel compelled to wait for clearer language from the government on the interoperability standards before investing?

"Meaningful use" is demonstrating to the satisfaction of the Secretary that the professional is using a certified EHR in a meaningful manner, which includes the use of e-prescribing, electronic HIE, and submission of information on clinical quality measures. Additional clarity on interoperability will be complete by the end of 2009. I do not believe clinicians should wait for all the details before investing. They should begin EHR implementation now.

5. What other details about meaningful use are listed in the bill?

-The Secretary may develop more stringent measures of meaningful use over time.
-For eligible professionals that are not meaningful users of EHRs, Medicare reimbursements will be cut 1% in 2015, 2% in 2016, and 3% in 2017.
-If less than 75% of professionals are meaningful users in 2018, Secretary can cut reimbursements another 1 percentage point, to maximum of 5%.
-Exceptions to the reimbursement reductions may be made on a case-by-case basis for hardships.
-The CMS Website will list eligible professionals who are meaningful EHR users.

6. Will Healthcare Smart Cards replace PHRs?

Smart cards have not received wide acceptance in any US industry, although they are very popular in other parts of the world. Reading and writing to smart cards would require a substantial investment in hardware throughout the healthcare industry. There are likely to be privacy concerns associated with lost or stolen smart cards. For all these reasons, I believe it is much more likely that web-based Personal Health Records, such as those provided by Google, Microsoft, and Dossia, will be more popular than smart cards. These PHRs are secure, protect confidentiality, and are automatically updated by labs, pharmacies, hospitals, and clinician offices.

7. Will clinicians be able to migrate easily from one EHR to another?

Interoperability in 2009 includes e-Prescribing, laboratories and clinical summaries needed for continuity of care. It does not include every field in the EHR. Conversion for one to EHR to another requires a combination of automated and manual data transfer. For the next few years, replacing one EHR product with another will still be a data conversion challenge.

8. What is the roadmap for interoperability?

See my blog on this topic. Over the past 3 years, HITSP has focused on Labs, Medications, Clinical Summaries, Public/Population Health, and Devices. In 2009 and beyond we'll add clinical research, newborn screening and close numerous gaps. In general, I believe meaningful use will include exchange of

Problems lists/Diagnoses
Medications including e-prescribing
Allergies
Text-based summaries
Quality data sets
Population health data sets submitted to CDC, public health departments, and other government agencies.


9. "After standards are adopted in 2009, the National Coordinator shall make available at a nominal fee an electronic health record, unless the Secretary determines that the needs and demands of providers are being substantially and adequately met by the marketplace. Nothing in the legislation requires that entities adopt or use the technology made available through this provision.” -from HITECH Act. Do you see this as a viable solution for small practices who want to wait it out and go with a cheaper software product?

See my blog on this topic. Open Source may provide reduced licensing cost, but other costs beyond license fees are the majority of implementation expenditures including practice workflow redesign, interfaces, and training. Open Source is an important part of the nationwide acceleration of EHR implementation, but it is not a panacea.

10. Do you see PHR’s and EHR’s as separate markets currently and what about in the future?

PHRs and EHRs are different products and I do not believe that PHRs will replace EHRs. EHRs are workflow tools for clinicians. PHRs are lifetime clinical summary and workflow tools for the consumer. They are complementary not competitive technologies.

Hail to the IT Chief

David Blumenthal MD, MPP, our new National Coordinator for Healthcare Information Technology (ONCHIT) is an icon in the Massachusetts community. The Associated Press release announcing his appointment is below. He's created numerous organizations, collaborations, and study groups to better understand the effective use of information technology in healthcare. In his youth, he worked on Kennedy's staff in Washington. He's advised Presidents. He understands the need to create policy and technology in parallel.

David will ensure the stimulus effort gets off to a great start.

Although I have not heard directly, I presume Dr. Rob Kolodner will continue to serve a role at ONCHIT to ensure all the deliverables specified in ARRA for 2009 get done on time.

It's a great time for healthcare IT and all its stakeholders. I'm honored to be associated with these folks.
-------

WASHINGTON (AP) — A former Harvard Medical School professor who has advised Sen. Edward Kennedy and one-time Democratic presidential candidate Michael Dukakis will lead health information technology efforts for the Obama administration.

Dr. David Blumenthal was also a senior adviser to President Barack Obama's presidential campaign.

The Health and Human Services Department announced the selection of Blumenthal as national coordinator for health information technology in a news release Friday.

Blumenthal will play a key role in determining how to spend $19 billion devoted to medical technology in the economic stimulus bill that became law last month.

Blumenthal most recently has been director of the Institute for Health Policy at The Massachusetts General Hospital/Partners HealthCare System.

He worked on Kennedy's Senate staff in the late 1970s and was chief health adviser to Dukakis' 1988 presidential campaign.

He has done extensive research on health information technology issues.

Letter to the Editor II

Dr. Bates, Middleton and I have been asked to respond to a letter in the Washington Post. Our response, including links to the appropriate studies/evidence, is today's blog.

Dear Editor:

As Harvard Medical School faculty and experts in healthcare information technology, we wish to respond to the March 17, 2009 article "Bad Bet on Medical Records" By Stephen B. Soumerai and Sumit R. Majumdar. Our response is below:

"Soumerai and Mejumdar’s critique of electronic health records and the investment being made in them in the U.S. by the Obama administration does not present a balanced view of the evidence. The U.S. already lags behind virtually every other industrialized nation with respect to Health Information Technology (HIT) adoption, especially outside the hospital. The evidence suggests that investing in HIT will pay for itself.

Their first point is that several randomized controlled trials of decision support for one particular area (management of a few chronic conditions) did not show benefit (Article 1, Article 2, Article 3) That is accurate. However, they have not included multiple other studies that show that there is benefit for other conditions like diabetes and heart disease (Article 4, Article 5, Article 6) The data about the benefits of HIT for chronic diseases are more mixed than for other areas, but clear benefits have been demonstrated.

Their next assertion is that health IT does not save money. There are numerous studies showing that it does (Article 7, Article 8, Article 9, Article 10, Article 11). For example, a detailed case study of the cost and quality benefits of EHR at Family Care of Concord, NH found net benefits per clinician per year of $30,324. Another study of hospital-based provider order entry identified net savings of $1.7 million per year from drug dosing guidance, nursing time utilization, and error prevention.

Soumerai and Mejumdar also suggest that information technology makes care less safe. They present data from Children’s in Pittsburgh, which found that children transferred in for special care had an increased mortality rate. They do not mention that this hospital implemented the system poorly (as has been well documented) and made many workflow changes that resulted in delays in care for sick children. Badly implemented software can certainly yield negative results. Other hospitals, including Children’s of Seattle, have implemented exactly the same vendor system, following best practices for implementation, and experienced a trend toward a lower mortality rate.

The authors refer to “modest” error reductions. In fact, the level of medication error reduction with computerization of prescribing seen in multiple studies is over 80%. That is more than modest.

Doing research takes years, years that we do not have if we are to avoid slipping even further behind the rest of the world in this key part of the economy. While we do need research in this area, it should focus on how to improve care, not whether or not to implement electronic health records. That is already clear. Physician and nurse-practitioner teams represent a good idea, but they will be much more efficient if they are supported by the right information technology. Furthermore, health information technology, once implemented, keeps delivering benefits which will grow over time, while approaches like physician-nurse teams require ongoing support.

If we are to deliver high quality care for patients with chronic conditions, electronic records with decision support are needed to help providers track all the many things that need to be done. These records should include tools that enable providers to manage populations of patients with certain conditions like diabetes, and to track their progress. Patients should have tools that allow them to access their records and more actively participate in their care. Finally, we need to provide economic incentives for delivering better care, which will get providers to focus on these issues.

If patients are to have high-quality, safer, lower-cost care, we must move to a digital world in healthcare. Doing so won’t ensure that care gets better by itself, but it is a pivotal step in the right direction.

David Bates MD, MSc is Professor of Medicine at Harvard Medical School, and Professor of Health Policy and Management at the Harvard School of Public Health.

John Halamka MD, MSc is Associate Professor of Medicine, and the Chief Information Officer at Harvard Medical School and Beth Israel Deaconess Medical Center

Blackford Middleton MD, MPH, MSc is Director of Clinical Informatics R&D, and of the Center for Information Technology Leadership, at Partners Healthcare."

Preparing for the Work Ahead

As we all prepare for the 5 year sprint to implement electronic health records for every clinician in America, I am preparing my life and my schedule for the work ahead in Massachusetts. Here are a few changes I'm making:

1. I'm reviewing my commitments to Boards and advisory groups. Although my commitment to these organizations individually does not amount to much time, the collective time spent can be substantial, especially if travel is involved. Over the next 60 days, I will substantially reduce these responsibilities.

2. I'm refining my avocations. Over the next 60 days, I will reduce my musical instrument lessons/practice to exclusively the Japanese flute, giving up the Turkish Ney and the Native American flute. I will eliminate rock and ice climbing trips, limiting my outdoor activities to local kayaking on the Charles and hiking with my family.

3. I will reduce my travel as much as possible. The notion of traveling for 24 hours for a 1 hour lecture no longer makes sense - the cost of the time is too great. Of course, Washington travel related to Healthcare IT does make sense and meetings I can join by video teleconferencing, webex and conference call are fine.

4. I will reserve time for Washington activities. I hope to serve on the new HIT Standards Committee as well as continue my HITSP service until I reach my term limit.

5. I will work to consolidate the Massachusetts organizations I serve. In discussions with the Boards of NEHEN and MA-Share, we hope to merge the two organizations. This will establish a unified health information exchange organization for Massachusetts (to be called the New England Health Exchange Network - NEHEN) that meets the criteria for HIE stimulus while reducing the number of meetings we all need to attend.

Thus, my streamlined life for the stimulus work ahead will be

*BIDMC CIO overseeing the application of stimulus funds for the hospital and 1533 affiliated clinicians - 1177 who have an EHR and 356 who do not

*Harvard Medical School CIO overseeing many stimulus related projects in research, high performance computing, education, and collaboration.

*NEHEN Chair overseeing many stimulus related healthcare information exchange projects.

*Very limited Board and advisory group service, focusing on activities that are complementary to my other stimulus related projects.

*Husband, father and son, limiting my avocation time to activities I can do with my wife, daughter, and parents.

*Limited travel, honoring my existing commitments in April and May but thereafter limiting my travel to Washington trips directly related to Healthcare IT activities (and HIMSS)

My life as a CIO must remain in balance, even as the challenges ahead increase. I look forward to the challenges and making Massachusetts a showplace of EHRs and interoperability for the country.

A Letter to the Editor

As I've mentioned in several blog postings, we're now living through one of the most exciting times in the history of healthcare information technology. With change comes controversy.

Over the past week, several articles have appeared in the press about the value of electronic health records and their impact on quality/safety/cost. David Bates, Blackford Middleton, and I have been asked to respond to them. Here's one of our upcoming responses.

Dear Editor:

As Harvard Medical School faculty and experts in healthcare information technology, we wish to respond to the March 11, 2009 article "Obama's $80 Billion Exaggeration" by Jerome Groopman and Pamela Hartzband. Our response is below:

"We already have clear evidence demonstrating that electronic records improve care and reduce costs when implemented well in specific settings. Three of many examples include:

1. We (Middleton) have published a detailed case study of the cost and quality benefits of EHR at Family Care of Concord, NH demonstrating net benefits per clinician per year of $30,324. This is comparable to the cost savings we've estimated in our academic health centers.

2. We (Middleton, Bates) have published a cost-benefit analysis of hospital-based provider order entry documenting at net savings of $1.7 million per year from drug dosing guidance, nursing time utilization, and error prevention.

3. We (Halamka, Bates) have documented cost savings from automating radiology and medication ordering processes to significantly reduce utilization, pharmacy costs, and staffing.

Much of this evidence comes from a few sites which developed their own records such as the Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center. Similar benefits should be possible throughout the country, but will require successful implementation and meaningful use of the new technology. Models by the Center for Information Technology Leadership and others suggest that the total financial benefits may be very large.

The United States is behind many other countries in implementing electronic health records. Most other industrialized nations are already using them and getting their benefits. They did this without cost-effectiveness analyses, simply because it was so obvious that there would be important benefits with respect to quality, safety and efficiency. Furthermore, nearly all the major integrated delivery systems have followed suit, such as Kaiser and Geisinger Healthcare System. The Veteran’s Administration system is nearly completely electronic, and that has played a large role in the high quality performance achieved by the VA.

Groopman cites a study which we (Bates, Middleton) did which found that implementation of electronic records was not associated with improved quality across the U.S. However, he did not cite the portions of that article documenting that performance does improve substantially when the right things are included in the record.

The electronic health record represents a transformational change in healthcare, and will enable an array of improvements—although it will not necessarily result if implemented badly. The electronic record is to the paper record as the automobile was to the horse and buggy. No one will want to go back.

President Obama’s incentives should result in a major increase in electronic record adoption in the U.S., and hopefully will bring us past a “tipping point” which will result in nearly complete adoption. This will result in higher quality, safer care, and lower costs. These are goals that all Americans want and can embrace.

David Bates MD, MSc, Medical Director of Clinical Quality & Analysis at Partners HealthCare.

John D. Halamka MD, MSc, Chief Information Officer at Harvard Medical School and Beth Israel Deaconess Medical Center

Blackford Middleton MD, MPH, MSc, Director of Clinical Informatics Research & Development at Partners HealthCare"

Electronic Health Records from Wal-mart

Many folks who read Steve Lohr's New York Times column last week "Wal-Mart Plans to Market Digital Health Records System" emailed me and asked - how can this be? The cost seems low, the products seem outside of the scope of Wal-mart's expertise and clinicians may not receive the expert implementation assistance and support that has been well documented to result in successful adoption of EHRs.

To answer this question, I spoke today with the CEO of eClinicalWorks, Girish Kumar, Linda Dillman, Executive Vice President of Benefits and Risk Management for Wal-Mart Stores, and Marcus Osborne, who leads Wal-Mart's healthcare business development team.

Here's the detail:

The cost for a full implementation of the eClincalWorks EHR purchased through Sam's Club is $25,000 for the first clinician in an office and $10,000 per additional clinician. It is a Software as a Service model, leveraging the cloud computing infrastructure that eClinicalWorks has deployed throughout the country. The price includes:

*Office hardware (desktops, laptops, printers)
*Installation of the hardware
*Installation of the eCW software clients which Dell includes as part of the operating system image on the hardware
*Data Center support
*e-Prescribing integration
*Specialty specific templates i.e. cardiology, pediatrics
*12 weeks of project management
*5 days of onsite training by eCW staff
*Free unlimited online webinars (offered 30 times/week)
*The first year of support

After the first year, all support and service is $500/clinician/month.

My experience implementing software as a service models at large scale in Massachusetts has achieved very similar pricing for hardware, software, implementation and support. It's a good deal.

Wal-mart is working on lab interfacing, so we'll hear more about that soon. In addition to the services provided directly by Wal-mart's vendors, Marcus told me that they will encourage complementary community implementation efforts (Regional HIT Extension Centers) to provide additional health information exchange, quality measurement, and local program management to ensure clinicians achieve meaningful use of this new technology. The cost of our BIDMC implementations is about the same as Wal-mart implementations when these additional services are considered.

Wal-mart believes healthcare information technology is within their realm of expertise because of their rich experience with acquiring and implementing IT for their own operations. Their supply chain savvy enables them to achieve best pricing from eCW, Dell, and other vendors in a single package that takes the guesswork out of buying an EHR. There is no RFP and no consulting expense for system selection.

Marcus also told me about their extensive process to select eCW and Dell. They reviewed dozens of vendors and technologies before choosing these partners.

Wal-mart hopes this effort to package hardware, software, implementation, training, and support services together will be disruptive. No longer will clinicians be spending over $60,000 per person to get started with EHRs. This is not turning EHRs into a commodity, it's achieving the best value for clinicians by leveraging economies of scale, cloud computing, and the supply chain.

There you have it - a complete EHR plan from Wal-mart. They've really thought through this one. I have great faith in their ability to make it a success.

The Timeline for ARRA Privacy Provisions

As a valuable reference tool, please feel free to circulate and use this specially bookmarked PDF of ARRA, (in Acrobat just click on View, Navigation Panels, Bookmarks to navigate the sections of the bill). Thanks to Robin Raiford of Eclipsys for creating it.

The timeline below is based on work by the Markle Foundation and the Center for Democracy and Technology. Thanks for their effort!

Upon enactment (February 16, 2009)
*Application of new tiered civil penalties based on the nature of HIPAA violations, up to $50,000 per violation and an annual maximum of $1.5 million (Section 13410)
*Enforcement by State Attorney Generals for offenses occurring post enactment (Section 13410e)

Within 45 days of enactment (April 3, 2009)
*Appointment of HIT Policy Committee members (Section 3002b)

Within 60 days of enactment (April 18, 2009)
*HHS Secretary will issue guidance on methodologies and technologies that render information unreadable (Section 13402)

Within 180 ays of enactment (August 16, 2009)
*HHS and the Federal Trade Commission will promulgate interim final regulations on notification of breaches. The FTC rules will apply to breach notification by PHRs that are not covered by HIPAA or Business Associate agreements (Section 13402, 13407)

By December 31, 2009
*HHS must adopt through rulemaking the initial prioritized set of standards which should include the accounting for disclosures (Section 3002b)

Due within one year post enactment (February 17, 2010)
*The Secretary will appoint a Chief Privacy Officer (Section 3001)
*The Office of Civil Rights and HHS will launch an education initiative to improve public transparency on the use of health information (Section 13403)
*The Government Accountability Office will report on best practices for disclosures for treatment and use of electronic informed consent (Section 13424)
*HHS will report on and provide guidance on de-identification (section 13424c)
*Covered entities must enter into Business Associate Agreements with PHRs, HIEs, and other services that handle projected health information (Section 13405e)
*HHS will issue rules on opting out of fundraising solicitations (Section 13406)
*HHS will report on guidance on the effective technical safeguards for carrying out the HIPAA security rule (Section 13401c)
*HHS and the Federal Trade Commission will report on privacy and security requirements for PHR vendors and applications

One year post enactment (February 17, 2010)
*HHS and the Office of Civil Rights clarify application of criminal penalties for non-covered entities (Section 13409)
*HHS to issue rules on which entities are required to be business associates (Section 13401)
*Right to restrict disclosures to health plans for services paid for out of pocket (Section 13405a)
*HHS Secretary required to conduct periodic audits of entities covered by HIPAA (Section 13411)
*Right of electronic access of records by patients takes effect (Section 13405e)

Within 18 months of enactment (August 17, 2010)
*HHS guidance on minimum necessary data (Section 13405c)
*Regulations regarding sale of data prohibition which take effect 6 months post promulgation (Section 13405a)

By 2011
*Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009 (Section 13405c)

24 months post enactment (February 17, 2011)
*Clarification of ability to pursue civil penalties when criminal penalties are not pursued (Section 13405)

By 2012
*Regulations for methodology for distributing penalties or settlement money to harmed individuals (Section 13410)

By 2013
*Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired after January 1, 2009 (Section 13405c)

By 2014
*GAO will report on the impact of ARRA (Section 13424)
*Initial deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before January 1, 2009 (Section 13405c)

By 2016
*Extended deadline for complying with new accounting and disclosure rules for information kept in EHRs acquired before January 1, 2009 (Section 13405c)

The Timeline for ARRA Technology Provisions

The American Recovery and Reinvestment Art includes numerous deadlines and milestones for technology. I thought it would be useful to provide a timeline for the work ahead:

Upon enactment (February 16, 2009)
*Additional funding to government agencies to enhance adoption of healthcare information exchange (Section 3011)
* Research and development programs (Centers for Health Care Information Exchange Integration). Grants will be awarded on a merit-reviewed, competitive basis. The purposes of the Centers include generating innovative approaches to technology integration through cutting-edge, multidisciplinary research, and HIT development. Eligible research areas include:
-Interfaces between human information and communications systems
-Voice recognition systems
-Software that improves interoperability and connectivity among health information systems
-Software dependability of systems critical to health care delivery
-Measurement of technologies on the quality and productivity of health care
-Health information enterprise management
-Health information security and integrity
-Technology to reduce medical errors (Section 13202)

Within 45 days of enactment (April 3, 2009)
*Appointment of HIT Policy Committee members - Section 3002(b)

After 45 days from date of enactment (April 3, 2009), but prior to 90 days (May 18, 2009):
*HIT Policy Committee makes recommendations to ONC on areas in which standards, implementation specifications, and certification criteria are needed included those to protect privacy, ensure security, account for disclosures, encrypt information and use EHRs for quality improvement (Section 3002)

Within 90 days of enactment (May 18, 2009)
*HIT Standards Committee will develop a schedule for assessment of the policy recommendations developed by the HIT Policy Committee (Section 3003)
*NIST to conduct pilot testing of standards and implementation (Section 3003 and Section 13201)
*Draft description of program for establishing regional centers for HIT Implementation Assistance (Section 3012)

Not later than 45 days after the HIT Standards Committee delivers recommendations to ONC
*ONC makes a determination whether to endorse each standard, implementation specification, and certification criterion for the electronic exchange and use of health information that is recommended by the HIT Standards Committee and delivers recommendations to HHS Secretary (Section 3001)

By December 31, 2009
*The HHS Sectretary (in consultation with other Federal Agencies) will determine what standards should be adopted from those endorsed by ONC, and adopt them through rulemaking processes (Section 3004)
*The Secretary will adopt an initial set of standards, implementation specifications and certification criteria through release of Interim Final Regulations (Section 3004)

After January 1, 2010
*Grants to standards and Indian tribes (for development of loan programs to facilitate adoption of certified EHR technology) (Section 3014)

By October 1, 2010
*Study and report to Congress on current availability of open source HIT systems to federal safety net providers and recommendations for legislative or administrative action (Section 4014)

After October 1, 2010
*State grants to promote HIT (implementation grants to facilitate and expand health information exchange, including required matches) (Section 3013)

Effective January 1, 2011
*Accounting of disclosures for EHRs acquired after January 1, 2009 (Section 13405)

Effective January 1, 2014
*Account of disclosures for EHRs acquired before January 1, 2009 (This is a grandfather clause which assumes older EHRs may not have audit trail functionality and gives vendors extra time to retrofit them) (Section 13405)

This is an audacious schedule and the folks at ONC are working 24x7 to meet the 2009 deadlines. Today is the deadline for nominations to the HIT Policy and Standards Committees. I've been nominated by ANSI for the Standards Committee.

Tomorrow, I'll post the timeline for ARRA Privacy Provisions.

Cool Technology of the Week

I've written about the consolidation of the devices I own and my use of the iPod Touch as an e-book reader, replacing my Kindle. On the day after I wrote that posting, Amazon announced Kindle software for iPhone/iPodTouch.

I downloaded the free application from the Apple App Store and gave it a try. Kindle for iPhone is compatible with any iPhone or iPod Touch running the iPhone 2.1 software update.

My first test was downloading books, since the Kindle for iPhone has no sample books included.

With Stanza, I just clicked on the Library tab, then Online Catalog, and was given easy access to Fictionwise, O'Reilly, Project Gutenberg and many others. I clicked on Project Gutenberg and downloaded Walden in about 3 seconds.

With the Kindle for iPhone, I clicked on the Get Books button and assumed I would be taken to an iPhone friendly version of Amazon.com. Unfortunately I was taken to a static page which told me to order books from Amazon on the web then synch them automatically to my device.

At first, I thought this to be a hassle and poor user interface design. Actually, it's not bad.

I can go to Amazon.com via Safari (or Firefox on my MacBook Air) and order any books I want using the one click ordering system, instantly making that title accessible to my mobile device via the WhisperSync application built into the Kindle for iPhone reader. Thus, I can take advantage of all the Amazon features I'm used to with the benefits of reading my purchases via my iPod touch. As a test, my wife and I searched for Amazon's free ebooks. We found a series of dimestore romances and a book called "Speed Dating" by Nancy Warren. It sounded better than "Slow Hands", "Kiss me Deadly", or "Once a Cowboy", so we ordered it.

I launched the Kindle for iPhone app and the Speed Dating text appeared. It took a few seconds for me to figure out the user interface - gesture forward to turn a page, touch the bottom of the screen to adjust font size/insert bookmarks/scan the table of contents, and press the Home button to return to my book list.

Although it works well, there are few missing features compared to Stanza. Turning the ipod touch while running the Kindle application does not display the book in landscape mode. I could not change the typeface or adjust the margins.

I suspect more features will be added in upcoming versions.

A seamless iPhone/iPod link to the 240,000 Kindle ebooks on Amazon - that's cool!

Cutting the Cord

Change is hard for everyone. Old habits are comfortable and moving to something different generally requires a learning curve.

Although I'm often an agent of change, I still experience feelings of stress of when I make radical leaps in technology or move to a major new workflow.

Over the past month I have eliminated my landline phone at Harvard Medical School. In these lean times, we're all looking for ways to reduce costs. The loaded cost for landlines at Harvard is $49/user/month for ISDN Centrex phones and $18/user/month for analog service. Some are downgrading from ISDN to analog. I eliminated my phone entirely.

There are several reasons for this

*Given my 24x7x365 lifestyle, asynchronous communication via email, blogs, Facebook, Twitter, and other social networking applications is much more efficient than phone calls

*I receive Blackberry email every minute, but check voice mail one a month

*I'm rarely sitting at a desk

In the past, I relied on a desk phone for press interviews, webinars and conference calls. I resisted the complete transition to a mobile phone. After realizing that my fears of dropped calls, poor sound quality, and lack of speakerphone features were unfounded, I decided that a mobile only approach to phones is good enough.

Yesterday was a good example of the kind of flexibility I need. While attending a meeting in Washington from 10am to 3pm, I also had to hold a webinar for 2500 people from a hotel lobby. This required me to use a cell phone and a laptop without a wireless network. I spoke and asked the conference organizer to advance the slides. It worked flawlessly. Gaining comfort with using a mobile phone for every task has required a change in my mindset - I no longer travel to a desk just to do a conference call or webinar. Emotionally, I'm still working through the change, but technologically there are no issues.

What about cellular phone quality? In most metropolitan locations, there is no issue, but at my home in Wellesley, there is spotty coverage from all cellular providers. To address this issue, I installed a cell tower in my basement - a FemtoCell. The Verizon Network Extender uses my home FIOS connection to create an inbuilding cell presence, giving me 5 bars of service throughout my home for a one time expense of $249 and no monthly fees.

At the moment, I still have a home landline, but that may go away too. American society is moving to wireless only communications like many other parts of the world. In China, Japan and Korea wireless far exceeds wired connections purely because of the timing of their technology implementations. Wireless became available before the country was wired, so there is no real need for wired phones. Additionally, the Japanese cellular is so good that WiFi is rarely used in the country. You get broadband speeds on cell phones throughout the country.

Thus, I've cut the cord. I'm not entirely adjusted to the change, but it's the right thing to do. I'm confident that the combination of cellular phones and Femtocells to ensure a good quality signal in my home is a winner.

The HIT Standards Committee

Today, HHS posted a call for nominations to the HIT Standards Committee.

I've previously described my hopes and expectations for the new HIT Committees:

"Although the ARRA's HIT Policy Committee and HIT Standards Committee are still being formed, I do have a few thoughts about how all our organizations will evolve.

These Federal Advisory Committees (FACAs) will advise the government. They will not advise industry, payers, providers, or patients. I believe the FACAs will need multi-stakeholder groups to do the work they prioritize and to coordinate with all the stakeholders in the healthcare IT ecosystem. I believe there will be an ongoing need to harmonize standards, especially around quality measurement mentioned in ARRA several times.

The HIT Policy Committee will be a new committee. NeHC, CCHIT and HITSP are not specifically submitting slates of candidates, but we will happily support any of our members who self-nominate.

The HIT Standards Committee is a new committee, but it is my hope that NeHC will evolve to become the HIT Standards Committee. As the new Secretary of HHS is confirmed, hopefully we will get clarity in this area.

It is my hope that HITSP will continue its work and will report to the HIT Standards Committee. I have the same hope for CCHIT and its certification mission.

Thus, the existing excellent people will continue to advance the work, but we'll have new governance and new resources. I've very optimistic that ARRA will align all of us to do great things for the country and the cause of interoperability. All folks that have led these activities in the past are aligned and ready to support the vision of the new secretary."

Today, the National eHealth Collaborative posted its hopes and expectations, which I wanted to share with you:

National eHealth Collaborative Statement regarding the call for nominations to the U.S. Department of Health and Human Services (HHS) HIT Standards Committee

“President Obama has made the rapid establishment of a national e-health information system a clear priority, and Congress has reinforced that goal through passage of the American Recovery and Reinvestment Act of 2009 (ARRA). This objective is central to the National eHealth Collaborative’s vision and mission of fostering the effective use of interoperable health information and leading the creation of a secure interoperable nationwide health system that will advance the public’s interest in health and improve the quality, safety, efficiency and accessibility of healthcare for all Americans.

The HIT Standards Committee established by the ARRA will bring central focus and urgency to the interoperability efforts needed for such a nationwide network through the development of national standards, and the Secretary of Health and Human Services was given the option by Congress to recognize the National eHealth Collaborative (NeHC) as this Committee. However, the ARRA sets an aggressive timetable, which understandably requires that HHS move forward with a nominations process even as we await confirmation of a new Secretary.

The goals of NeHC and those of the HIT Standards Committee are highly complementary. NeHC’s unique membership constitution represents the full spectrum of public and private sector e-health stakeholders, including consumers and patients, healthcare providers, employers and payers, government officials, information technology experts, quality improvement experts, public health researchers, and privacy advocates, and in this time of urgent need for economic and healthcare reform, an already established and cross-functioning group of experts would be a strong asset to the work envisioned by the legislation. We remain committed to this possibility, and look forward to quickly engaging in a discussion about this and other possible NeHC contributions with Secretary-Designate Kathleen Sebelius upon her confirmation.

The National eHealth Collaborative strongly believes that a unifying public-private partnership is key to successfully implementing President Obama’s goal of an Electronic Health Record for every American by 2014. NeHC will continue to provide leadership and engage individuals, providers, institutions and all other stakeholders in a collaborative forum, working toward the shared goal of aggressively stimulating the use of health information technology in order to significantly improve the health and well being of all Americans, while respecting and protecting their privacy and security.”

I look forward to all our continued work together!

Making Smart Investments In HIT

In today's issue of Health Affairs, I wrote an article highlighting 5 guiding principles for spending stimulus funds wisely. You can download it online

Here's the abstract:

Making Smart Investments In Health Information Technology: Core Principles

Over the past five years, thousands of public- and private-sectoremployees, many volunteering their time, have worked to advancethe cause of interoperable, certified, secure electronic healthrecords. As new federal funds become available, should we investright away or wait for technology and policy perfection? Dowe leverage the accomplishments of existing national organizations,or do we start from scratch? The time to invest is now, buildingon the organizations we already have. To ensure wise investment,I suggest guiding principles assembled from the input of hundredsof providers, patients, payers, vendors, government employees,and standards-development organizations.

Your comments are welcome!

Stimulus Modeling and Accountability

As well all prepare for the work ahead, many in healthcare are beginning to model the potential payments and design the reporting systems needed to account for the money spent.

I've promised to share all the BIDMC work we're doing as it happens, so here's a near real time update.

Our CFO, Steve Fischer used the guidance from the American Hospital Association to compute BIDMC's share.

You'll see that we are expecting $6.3 million because we anticipate "meaningful use of EHRs" by all our clinicians in 2011.

The computation for hospitals is calculated as Medicare’s share of the sum of $2 million plus an additional discharge-related amount. A hospital receives $200 for each discharge for discharges starting with its 1,150th and continuing through its 23,000th discharge. There is no additional payment for discharges outside of this range – which means that the largest discharge-related amount available to any hospital equals $4,370,200. The largest total amount available would be $6,370,200 ($2 million plus $4,370,200). This figure is multiplied the medicare share of inpatient days, then summed over 4 years with a decreasing payment each year - 100%, 75%, 50%, 25%

In addition to direct Medicare funding, we're anticipating grants for research, education, and health information exchange. I'm often asked how we'll report our use of such funds. Pete Orszag, the Director of OMB, has offered detailed guidance based on 5 guiding principles:

• Funds are awarded and distributed in a prompt, fair, and reasonable manner;
• The recipients and uses of all funds are transparent to the public, and the public benefits of these funds are reported clearly, accurately, and in a timely manner;
• Funds are used for authorized purposes and instances of fraud, waste, error, and abuse are mitigated;
• Projects funded under this Act avoid unnecessary delays and cost overruns; and
• Program goals are achieved, including specific program outcomes and improved results on broader economic indicators.

I hope this background is helpful to you as you prepare for the Stimulus work ahead

Forward, Forever Forward

The American Recovery and Reinvestment Act doubles the size of the healthcare IT industry. The details of the work ahead, how we'll organize to accomplish the work and who will do the work are still being developed. In the meantime, I'm getting involved in every discussion, debate, and brainstorming opportunity that I can to move the work forward.

This will be a busy week. On Wednesday I'm joining the Markle Connecting for Health kick-off meeting to discuss key issues for implementation of ARRA. On the same day, I'm giving a HIMSS Webinar with Mark Leavitt and Dave Roberts to discuss our best thinking about ARRA.

Here are a few thoughts as I prepare for these venues.

Carol C. Diamond MD, MPH Managing Director, Markle Foundation and Chair, Markle Connecting for Health recently testified to the National Committee on Vital and Health Statistics:

"The initial focus should be on only the critical standards for sharing data — the way it moves from point A to point B over the internet. This would involve initially specifying interface, transport and security standards rather than standards for data expression or the behavior of local applications, because the critical predictor of good outcomes and cost- effectiveness is whether or not data is able to move between a person’s various authorized providers."

I agree with her point that interface, transport and security standards are a high priority.

In my own experience in Massachusetts, we created the NEHEN gateway appliance in 1997 to provide a standardized, secure transport system for many types of healthcare data between payers and providers. An appliance is just a self contained hardware and software system. In the case of NEHEN, the Massachusetts community created open source software on commodity servers that is managed by NEHEN so there is minimal impact on the hosting IT organizations.

It started as secure FTP, then evolved to HTTP over frame relay/VPN, then evolved to web services called Healthcare Transaction Services which are now recognized by CAQH as their preferred transport architecture. The beauty of having a secure transport appliance is that it enables interoperability to evolve rapidly in the community. Massachusetts started with benefits/eligibility then added referral/auth, claims, and claims status inquiry, all using X12 content standards. Then, we decided to implement e-prescribing for the State using NCPCP Script standards and leveraged our secure transport gateway to rapidly connect our provider organizations to RxHub/Surescripts. Our Eastern Massachusetts Health Initiative prioritized clinical summary exchange and we began using the Continuity of Care Document to send discharge summary payloads through our appliances. Finally, quality measurement is becoming increasingly important to CMS and our local payers. We're implementing HITEP/HITSP standards for quality data set transmission through our appliances.

Today the country has several different implementations for secure transport of healthcare data

NEHEN's Healthcare Transaction Services
The Social Security Administration Megahit pilot
Nationwide Health Information Network pilots
Google's GDATA API for Google Health
Microsoft API for HealthVault
and many others

All use variations of the same standards that HITSP has harmonized in its TN900 Security and Privacy Technical Note such as SOAP, WS*, REST, TLS, and HTTPS.

However, each of these implementations is a bit different, making them incompatible with each other.

Just as NEHEN built a single appliance for all transport between stakeholders in Massachusetts, I think it is reasonable to follow Carol's recommendation and ensure that every healthcare IT stakeholder implements transport the same way. If we all agree on one way to get data in and out of Google, Microsoft, payers, providers, and government, then the remaining issues are just related to content. HITSP has already done a good job on content standards.

To me, the ARRA provides a great opportunity for all of us - HITSP, NHIN Pilots, Connecting for Health, vendors, and government to converge on a single appliance for transport. Note that this appliance can be implemented by multiple different vendors on multiple different platforms. It could exist as open source and proprietary, just as Apache and IIS are both web servers that implement the same interface, transport and security standards.

To this end, the HITSP Foundations Committee has been working on a revision of all the HITSP content standards to express them in a Service Oriented Architecture. As this is done, we'll have to agree upon the following architectural elements

* Push: Subscribe, Publish
* Pull: Query/Locate, Retrieve Record(s)
* Record Envelope
* Record Addressing
* Authorization
* Source Signature
* Author Signature
* Source/Author Authentication
* Record Content Integrity
* Sender/Receiver Authentication
* Payload Encryption

In the past, HITSP has been required to stay architecturally neutral in all its work, but as we implement ARRA as a country, we're going to have to get very specific about architecture. I look forward to working with all the stakeholders on the specifics and ensuring there are common interface, transport and security standards implemented in every EHR, PHR, payer system, and quality measurement system.

At noon on Wednesday, I'll join the HIMSS Webinar The Act’s Impact on ONC, the National eHealth Collaborative, CCHIT, and HITSP

Although the ARRA's HIT Policy Committee and HIT Standards Committee are still being formed, I do have a few thoughts about how all our organizations will evolve.

These Federal Advisory Committees (FACAs) will advise the government. They will not advise industry, payers, providers, or patients. I believe the FACAs will need multi-stakeholder groups to do the work they prioritize and to coordinate with all the stakeholders in the healthcare IT ecosystem. I believe there will be an ongoing need to harmonize standards, especially around quality measurement mentioned in ARRA several times.

The HIT Policy Committee has already been announced:

"The American Recovery and Reinvestment Act of 2009 directs the Government Accountability Office (GAO) to appoint 13 of 20 members to a Health Information Technology (HIT) Policy Committee.

This Committee is to make recommendations on the implementation of a nationwide health information technology infrastructure to the National Coordinator for Health Information Technology.

The Act requires GAO to make appointments in the following categories:
(1) 3 members who are advocates for patients or consumers
(2) 2 members representing health care providers, one of whom is a physician
(3) 1 member from a labor organization representing health care workers
(4) 1 member with expertise in health information privacy and security
(5) 1 member with expertise in improving the health of vulnerable populations
(6) 1 member from the research community
(7) 1 member representing health plans or other third-party payers
(8) 1 member representing information technology vendors
(9) 1 member representing purchasers or employers
(10)1 member with expertise in health care quality measurement and reporting"

It will be a new committee comprised of great people. NeHC, CCHIT and HITSP are not specifically submitting slates of candidates, but we will happily support any of our members who self-nominate.

The HIT Standards Committee call for nominations has not yet been circulated. My belief is that we'll see it next week. It is my hope that NeHC will evolve to become the HIT Standards Committee. As the new Secretary of HHS is confirmed, hopefully we will get clarity in this area.

It is my hope that HITSP will continue its work and will report to the HIT Standards Committee. I have the same hope for CCHIT and its certification mission.

Thus, the existing excellent people will continue to advance the work, but we'll have new governance and new resources. I've very optimistic that ARRA will align all of us to do great things for the country and the cause of interoperability. All folks that have led these activities in the past are aligned and ready to support the vision of the new secretary.

I hope you join the webinar (2500 folks have already signed up).

Here's to the future!

Cool Technology of the Week

Yesterday, Google Health quietly launched a disruptive technology - social networking for personal health records.

Here's how it works.

In your Google Health profile, you click on Share this Profile. You can then invite anyone by email to share your medical record. To test the application, I invited my wife to join (see screen shot above).

Once you've invited others to see your medical record you can monitor audit trails of who has accessed your records, what they saw and when the looked. You can remove access at any time.

On the receiving end, your invitees receive an email with login instructions to view your medical records. They cannot change or add to your records. All their actions are audited.

Everything is done securely via HTTPS.

As a country, we continue to debate the appropriate privacy policy for sharing records in ways that protect confidentiality. We continue to work on technology solutions that restrict the flow of information to those we need to see it, when they need to see it, with the minimum need to know. These are all hard problems.

The Google solution, introduced without fanfare, solves many confidentiality issues by putting the patient in control of medical record sharing. Call it "Facebook for Healthcare". You invite those who you believe should see your medical information and you can disinvite them at anytime.

I've already invited my primary care doctor, my family, and a few of my clinical systems colleagues who built the BIDMC-Google interface. Thus, in one morning I've become my own regional health information organization, sharing medical records across multiple organizations with perfect privacy controls.

Social Networking for Personal Health Records - that's cool!

Do Your Best Today

I've written several blogs about being a parent , a husband , and a son.

Today's blog is about a simple statement my daughter made that applies to every one one of my roles.

She said "Do Your Best Today".

These words are important to me.

Life as a CIO is really not a job, it's a lifestyle. I really do not know what each day will bring. There could be great joys of lives saved through the innovative use of IT. There could be budget stresses, conflict, or politics. There could be unexpected new project priorities or a particularly satisfying consensus about a strategic path forward.

As I wrote in my Setting Expectations blog entry, it is very challenging to judge the success of each day, each week, or each year because there are few specific objective criteria that meet the definition of success for all stakeholders.

The simple objective way I can judge my progress is by knowing I did my best today.

* I treated my customers with respect and listened to their needs, even if I could not implement every one of their requests
* I navigated the politics of every situation without criticizing others or inflating my own self importance
* I left the stress at the office behind and brought laughter to our family dinner
* I put aside my email and helped work through a complex question on my daughter's chemistry homework (why is the surface tension of Acetone higher than Ethanol despite the hydrogen bonding in Ethanol that should create higher inter-molecular forces)
* I supported my employees through challenging decision making processes
* I moved forward every project as much as it could be moved, including a new breakthrough in community clinical data exchange
* I helped my parents choose a new digital television for their kitchen
* I spoke with the press to speculate on the next steps needed to enhance rollout of electronic health records nationwide
* I taught a course to MBA students at Boston University eager to find opportunities in stimulus-related work
* I fixed a clogged bathtub drain

As a parent, I want my daughter to be successful, but my definition of success is mine, not hers. I could tell her "Get straight A's in your honors classes today" or "Do amazing extracurricular activities that appeal to Ivy League Universities". Instead, "Do Your Best Today" empowers her to set priorities - personal, educational, and family. She'll learn to triage the most important tasks and over time she'll learn the joy of success instead of the fear of failure.

We'll all have good days and bad days, high highs and low lows.

Do Your Best Today. You'll be okay.

The Quality Data Warehouse Project

Many folks involved in healthcare IT and interoperability agree that we should not implement technology for technology's sake, instead we should focus on specific outcomes empowered by technology.

As we've implemented EHRs at Beth Israel Deaconess and throughout the state via the Massachusetts eHealth Collaborative, we've focused on the "model office" and process redesign. We build in decision support and quality measurement as part of the design.

How do you measure quality for an entire community?

I've written about the work of HITEP/HITEP II to create minimum quality data sets and about HITSP's work on the Quality Use case.

These efforts have been foundational to our thinking in Massachusetts.

Over the past year, the Massachusetts e-Health Collaborative has implemented a quality warehouse for the 300 practices in 3 communities and now we're adding the 1000 clinicians from Beth Israel Deaconess and BIDPO to this infrastructure. We think this kind of health information exchange is exactly the type of interoperability encouraged (and required by) the American Recovery and Reinvestment Act.

Here's how we're doing it.

The Massachusetts eHealth Collaborative rolled out EHRs from several vendors (eClinicalWorks, NextGen, Centricity, Allscripts) to 300 practices in 3 communities. Working with the communities, MAeHC created citywide health information exchanges. North Adams runs a Continuity of Care Record-based exchange created by eClinicalWorks. Brockton and Newburyport run an XDS-based clinical exchange created by Wellogic. All these exchanges submit quality data via HL7 2.x messaging and web services transport into a quality warehouse operating by MaeHC and hosted at the Massachusetts Medical Society.

Information exchanged includes

Problems
Procedures
Allergies
Medications
Demographics (encrypted identifiers)
Smoking status
Visits
Diagnosis
Lab results
Rad results

As we take this infrastructure to the next step, we are embracing the HITEP work and HITSP standards to implement quality reporting for the 700 clinicians using Beth Israel Deaconess' home-built EHR called webOMR and the 300 community-based clinicians using our our hosted eClinicalWorks Software as a Service offering. We'll use the Clinical Document Architecture/Continuity of Care Document to standardize the content of the data and we'll use the CAQH Core standards/SOAP for secure transport. The MA-Share/NEHEN gateways that we've used for all other data exchange in the state will provide the infrastructure/architecture to do this.

For all the details on the quality measures, the reporting, and the architecture, we've created this Powerpoint presentation.

This project has five goals for our community
1. Beth Israel Deaconess and its clinicians need to measure quality as a community to ensure we are clinical integrated and to quality for pay for performance incentives offered by our payers
2. The Eastern Massachusetts Healthcare Initiative, a collaboration of all the healthcare stakeholders in Eastern Massachusetts has prioritized quality measurement as one of our regional IT goals for 2009
3. The American Recovery and Reinvestment Act highlights the need for clinicians to exchange quality measurement data in order to qualify for incentives
4. The National Quality Forum/HITEP II would welcome a testbed for their work
5. The Massachusetts Medical Society wants to pilot quality measurement reporting for its members using the MAeHC

Thus, a focus on quality measurement, leveraging the MA-Share/NEHEN infrastructure and building up on the MAeHC warehouse will meet the goals of many stakeholders. It's a perfect storm.

A Do it Yourself Board Presentation

President Barack Obama officially nominated Kansas Governor Kathleen Sebelius as HHS Secretary and named former HCFA administrator Nancy-Ann DeParle as Counselor to the President and Director of the White House Office for Health Reform.

Now that national healthcare leadership is imminent, hospitals, provider groups, payers, vendors, and patients are anticipating action on the next steps outlined by the American Recovery and Reinvestment Act. Every IT professional in the land is being asked to present an overview to their Board summarizing the possibilities.

As a public service, I have created an overview presentation which summarizes all the healthcare IT provisions of the Act and outlines the incentives and penalties for physicians and hospitals.

You have my permission to use this presentation for your organization without attribution or copyright restriction . I did my best to interpret the Act accurately, but cannot guarantee that every word is precisely right (it's long and complex legislation).

Over the next few weeks, I will outline some of the steps we're taking in Massachusetts to prepare for the work ahead. For example, tomorrow's blog will describe BIDMC/BIDPO and Massachusetts eHealth Collaborative efforts to create quality data warehousing based on healthcare information exchange. Given the number of times that quality measurement and healthcare information exchange is mentioned in the Act, it seems prudent to get this started and empower all our local stakeholders by meeting those stimulus incentive criteria.

It's an exciting time and I believe all healthcare IT organizations will benefit from enhanced collaboration - "all for one and one for all". Hence I will be especially transparent about our plans, sharing the presentations I am preparing so they may be leveraged by all stakeholders.

Kathleen Sebelius, Healthcare Reform and the Budget

Today, according to the Associated Press and Washington Post, President Obama will announce Kathleen Sebelius as his nominee for Secretary of Health and Human Services. She has a once in a lifetime opportunity to execute healthcare reform - a popular President, a sense of urgency, and enough resources to get the job done. What are these resources?

You'll find the Office of Management and Budget FY2010 Budget Overview Document online The full FY2010 Budget is expected to be released this Spring.

Highlights from the Healthcare portion of the overview document include:

* A reserve fund of more than $630 billion over 10 years to finance fundamental reform of our health care system, funded half by new revenue and half by savings proposals that promote efficiency and accountability, align incentives for quality, and encourage shared responsibility. Examples of new revenue include a proposal that individuals earning more than $85,000 pay higher premiums for their Medicare drug coverage starting in 2011. Examples of savings include a revision of payments to insurers that provide Medicare Advantage plans. Those payments have been on average 14% higher than what the government typically spends per beneficiary. Under the budget proposal, insurers would be required to competitively bid to offer plans beginning in 2012, which the administration believes would lower per-patient outlays.

* The Budget expands research comparing the effectiveness of medical treatments. Building on the unprecedented $1.1 billion included in the Recovery Act for comparative effectiveness research, the Administration will continue efforts to produce state-of-the-science information on what medical treatments work best for a given condition.

* The Budget includes language to "Strengthen Program Integrity," noting that reducing fraud, waste, and abuse is an important part of restraining spending growth and providing health care quality service delivery to beneficiaries. The Budget proposes to dedicate additional resources that will initially be targeted to improving oversight and program integrity activities for the Medicare Prescription Drug Program (Part D), Medicare Advantage, and the Medicaid Program.

* The Budget includes over $6 billion within the National Institutes of Health (NIH) to support cancer research. This funding is central to the President's sustained, multi-year plan to double cancer research. These resources will be committed strategically to have the greatest impact on developing innovative diagnostics, treatments and cures for cancer. This initiative will build upon the unprecedented $10 billion provided in the Recovery Act, which will support new NIH research in 2009 and 2010.

* The Budget includes $330 million to address the shortage of health care providers in certain areas. The Budget's new resources will sustain the expansion of the health care workforce funded in the Recovery Act.

*The Budget includes continued efforts to accelerate the adoption of Health Information Technology, building on funding provided in the Recovery Act.

The combination of a reserve fund to accelerate transformation/additional coverage, comparative effectiveness data, enhanced operations, a strong NIH, and appropriate numbers of primary care physicians is a powerful array of resources.

As with any change process, she'll encounter resistance from some stakeholders and will be distracted by the tyranny of the urgent (naming a new head of the FDA to help address the recent peanut butter salmonella contamination problem, a perceived failure of our food safety systems). However, I am confident that government, payers, providers, and patients all recognize that our current healthcare system provides low quality/high cost (poor value) care which reduces our ability to compete in world markets. The FY2010 budget summary reflects a serious amount of resources and a commitment to change that is likely to move us forward.

Best of luck Kathleen and welcome to Washington!